Dr. Neil Calman, president and CEO of the Institute for Family Health, helps patients manage their housing, finances and food-buying so that they can live healthier lives. But the existing Medicaid model does not pay him for his efforts, even though those initiatives help his patients avoid expensive hospital stays.

“We have an enormous social-work department, but all of their work is completely unreimbursed,” said Dr. Calman.

That is about to change.

State Medicaid reform initiatives are beginning to pay health care providers to keep New Yorkers out of hospitals rather than for the services they provide when patients are gravely sick. The shift is part of the state’s $7.4 billion five-year Medicaid reform known as DSRIP. The goal is to cut avoidable hospitalizations by 25% by keeping New Yorkers healthy through better primary care from the start.

Getting paid

To achieve that reduction, hospitals and doctors are partnering with social-service nonprofits in low-income communities, where staying healthy may have less to do with medical care than with better housing and healthier eating.

Montefiore Medical Center launched a program with the YMCA to prevent pre-diabetic patients in the Bronx from developing A full-blown version of the disease. A 16-week class at the Y or in a Montefiore clinic teaches patients how to cook, where to shop for fresh food and ways to exercise.

“A lot of people don’t know this stuff,” said Dr. Amanda Parsons, Montefiore’s vice president for population health.

Dr. Parsons has cajoled bodegas into stocking healthier options. Patients in Montefiore’s program have lost an average of 6.6 pounds, or 3% of their body weight.

“A lot of doctors are saying, ‘We can’t get patients to lose weight.’ So we say, ‘We get that,’ ” she added. ” ‘Just send your patients to us.’ “

Treating New Yorkers with histories of mental illness or substance abuse is particularly costly to taxpayers.

“They might go to the emergency room 50 times a year,” said Len McNally, who was director of health initiatives at the New York Community Trust for 25 years before retiring.

Under the new reforms, for example, a health care provider could work with a housing group to ensure New Yorkers have a place to live and don’t end up in the emergency room during the dark of winter.

Another nonprofit that has started to work with managed-care companies is a.i.r. NYC, an organization that helps asthmatic children in poor neighborhoods learn how to manage their illness. It teaches them to use their medication regularly and avoid environmental triggers.

The nonprofit has a presence in many hospitals and schools, and has been funded by grants and private donations since its 2011 launch. But recently, it contracted with two Medicaid managed-care plans that will pay it to work with individual patients.

Medicaid partners

The nonprofit hopes to expand its reach and revenue under the Medicaid reform program, said Executive Director Shoshanah Brown.

“Community-based organizations like ours that are close to the ground and are very much in the community” can keep patients healthier, she said.

The nonprofit group God’s Love We Deliver also sees promise in the new program. It distributes nutritional meals for people recently released from the hospital as well as those who can’t cook for themselves. There is medical evidence that food plays a role in keeping people healthier and therefore away from expensive hospitalizations.

“I’ve seen a sea change in the appreciation of food,” said Karen Pearl, chief executive of God’s Love We Deliver.

The group is a partner in 14 new networks that were created by the Medicaid reform program. It also subcontracts with several Medicaid managed-care plans. Under such arrangements, the managed-care company pays God’s Love for each meal delivered to one of its Medicaid beneficiaries.

“Every day that we can help avoid one day in the hospital for somebody, that one-day savings can pay for half a year of medically tailored meal delivery,” said Ms. Pearl.